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The Radiology of Malrotation PowerPoint Presentation

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Description : Check out this medical presentation on Radiology and Imaging, which is titled "The Radiology of Malrotation", to know about the imaging modalities in the evaluation of malrotation.

Tags : Radiology, Imaging, Malrotation, modalities, evaluation

Published on : Jul 28, 2021 | Views : 3016 | Downloads : 4

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Slide 1-

The Radiology of Malrotation Thomas Boulden, MD
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Disclosures I am single. I am straight. I am available. Recent tax return and health information available on request
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Objectives What is the primary underlying problem in patients with malrotation and how can imaging best assess it? What is the expected position of the DJJ (duodenojejunal junction) or ligament of Treitz? What are the most common errors leading to the misdiagnosis of malrotation?
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Objectives 4. What imaging modality is least useful in the evaluation of malrotation? Upper Gastrointestinal Series Contrast Enema Ultrasound Computed Tomography MRI 5. Who is Alexander Bill?
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QuickTime™ and a decompressor are needed to see this picture. Rotation of Midgut LAO view
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Normal Rotation
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Nonrotation Malrotation in sensu strictiori stricto Reverse rotation
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Twist and Shout
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Dr. Václav Treitz (1819-1872) William E Ladd (1880-1967)
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Ladd Procedure Alexander Bill, a student of Ladd, modified the procedure by suturing the duodenum to the fascia overlying the right kidney and the cecum to the left inner abdominal wall in an attempt to prevent recurrent volvulus. Ladd’s Bands Two patterns of colon malposition with Ladd’s bands obstructing the duodenum
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Epidemiology Incidence: 1 in 6,000 to 1 in 200 live births Autopsy findings suggest that 0.5 to 1% of the population is affected Male to Female ratio 2:1 75 % present in the first month of life 90 % present in the first year of life 70% of patients with heterotaxy have malrotation
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Features of questionable malrotation include: Asymptomatic/incidental findings in investigating for reflux (fussiness, arching, apneic events, reactive airways, pneumonia) Intermittent vomiting No signs of acute illness. Features of intermittent or partial volvulus or obstructing Ladd's bands include: Intermittent vomiting No signs of acute illness Intermittent abdominal pain (typically post-prandial) Weight loss. Summary of Clinical Findings
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Features of obstruction without ischemia (midgut volvulus without vascular compromise) include: Bilious vomiting Crampy abdominal pain in waves Non-tender abdomen Non-distended abdomen No severe physiological disturbance. Features of obstruction with ischemia (midgut volvulus with vascular compromise) include: Acutely ill patient with severe acute abdominal pain Bilious vomiting Tachycardia Tachypnea Abdominal tenderness Acidosis Signs of peritoneal catastrophe (re-bound and guarding). Summary of Clinical Findings
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Syndromes Associated with Malrotation Apple-peel Intestinal Atresia Cornelia de Lange Syndrome Cantrell Syndrome Cat-eye Syndrome Chromosomal abnormalities (Trisomies 13, 18, and 21) Coffin-Siris Syndrome Familial Intestinal Malrotation Heterotaxy (asplenia, polysplenia) Marfan Syndrome Meckel Syndrome Mobile Cecum Syndrome Prune Belly Syndrome
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Anatomic Anomalies Associated with Malrotation Absence of kidney and ureter Biliary atresia Congenital diaphragmatic hernia Duodenal or small-bowel stenosis or atresia Duodenal web Gastroschisis Hirschsprung disease Imperforate anus Intestinal pseudo-obstruction Intussusception Malabsorption Meckel’s diverticulum Omphalocele Pyloric Stenosis
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Radiography
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Duodenal Atresia Meconium Ileus Midgut volvulus in a 4 year-old
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Contrast Enema
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Nonrotation Malrotation with normal position of cecum in right lower quadrant
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Contrast Enema 80% of patients with malrotation demonstrate an abnormal position of the cecum 20% of infants with malrotation have a normal cecal position 15% of patients with normal rotation have a mobile cecum Does not show the volvulus as well as the upper GI
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Upper GI
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Rules of the Upper GI Evaluate the duodenum on the first upper GI on every patient Document the first pass of barium through the duodenum Document the duodenum in the frontal and lateral projections
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Performing the Upper GI Concentrate on the duodenum Control the barium Moderate amounts, don’t over-distend the stomach An enteric tube adds additional control Turn the patient with purpose Avoid placing the right side down until you are ready to evaluate the duodenum
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Performing the Upper GI With the right side down allow moderate amount of barium to pass into the duodenum Once barium enters the duodenum quickly place the patient flat to evaluate the duodenal sweep Once the DJJ is documented in the frontal view quickly turn the patient lateral to document it in this projection
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Normal position of the DJJ on Upper GI Frontal view DJJ is as cephalic as the duodenal bulb DJJ is no further to the right than the left pedicle of the adjacent vertebra Lateral view The 2nd portion of the duodenum descends posteriorly in the retroperitoneum The 4th portion of the duodenum ascends posteriorly in the retroperitoneum just anterior to the descent of the 2nd portion of the duodenum
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Frontal Lateral
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Frontal view shows the position of the duodenal bulb (arrow), which is superimposed over the gastric antrum, and inferior displacement of the duodenojejunal junction (arrowhead) Frontal view shows a similar inferior position of the duodenojejunal junction (arrow); * = duodenal bulb. Normal variants mimicking malrotation
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Normal variants mimicking malrotation Duodenal distortion due to marked gastric distention
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Normal variants mimicking malrotation “Wandering duodenum” or Duodenum inversum in an infant with vomiting
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Normal variants mimicking malrotation Duodenum inversum in an 11 year-old male
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Malrotation with obstructing duodenal bands
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Malrotation with obstructing duodenal bands
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Malrotation with midgut volvulus
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Malrotation with midgut volvulus
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Malrotation with midgut volvulus and obstruction with beaking of the duodenum
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Malrotation without volvulus
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Malrotation without volvulus in a teenaged male
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Error and Pitfalls Not seeing the first pass of barium Oblique positioning in the AP projection Mobility of the DJJ
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What do we do when we don’t know... Show the case around to our colleagues Follow the barium to the cecum Turn the UGI into a small bowel follow- through Do a contrast enema Repeat the study in a few days
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What do we do when we don’t know... Show the case around to our colleagues Follow the barium to the cecum Turn the UGI into a small bowel follow- through Do a contrast enema Repeat the study in a few days Equivocate
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Ultrasound/CT
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SMV in 12 o’clock position relative to SMA Right-sided small bowel Left-sided large bowel
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SMV in 2 o’clock position relative to SMA Left-sided colon with acute appendicitis
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SMV in one o’clock position relative to SMA SMV in two o’clock position relative to SMA
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Ultrasound Upper GI demonstrates duodenal obstruction due to midgut volvulus
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Whirlpool Sign of Midgut Volvulus - US
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Whirlpool Sign of Midgut Volvulus - CT
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211 patients 135 Normal US 130 Normal UGI 5 Abnormal UGI 76 Abnormal US 44 Normal UGI 32 Abnormal UGI Journal of Pediatric Surgery 2006;41:1005-1009
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AP orientation of SMA and SMV Positive predictive value 10% Negative Predictive value 90.1 % Inverted orientation of SMA and SMV Positive predictive value 41.7% Negative Predictive value 96.6 % Whirlpool sign of SMA and SMV Positive predictive value 71.4% Negative Predictive value 97.1 %
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One study found a false positive rate of 15% among pediatric radiologists. The ligament of Treitz is not a fixed position in infants. The underlying problem in malrotation is a short root of the mesentery. In difficult cases the length of the mesenteric pedicle can assessed by determining the distance between the cecum and the DJJ either by small bowel follow through or a combination of an upper GI and a contrast enema
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Post test What is the primary underlying problem in patients with malrotation and how can imaging best assess it? What is the expected position of the DJJ (duodenojejunal junction) or ligament of Treitz? What are the most common errors leading to the misdiagnosis of malrotation?
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Post test 4. What imaging modality is least useful in the evaluation of malrotation? Upper Gastrointestinal Series Contrast Enema Ultrasound Computed Tomography MRI 5. Who is Alexander Bill?